1295810653 NPI number — ROBERT BEREN M.D.

Table of content: ROBERT BEREN M.D. (NPI 1295810653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295810653 NPI number — ROBERT BEREN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEREN
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295810653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12900 PARK PLAZA DR STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CERRITOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90703-9329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-977-4674
Provider Business Mailing Address Fax Number:
562-741-4479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4821 N STONE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85704-5727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-409-4299
Provider Business Practice Location Address Fax Number:
520-293-1957
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  18791 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 689877 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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